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Interact CardioVasc Thorac Surg 2006;5:S187-S247. doi:10.1510/icvts.2006.0000S4 © 2006 European Association of Cardio-Thoracic Surgery AbstractsSuppl. 2 to Vol. 5 (September 2006)
001 - O NEOCHORDAE AS THE PRIMARY TECHNIQUE FOR REPAIR OF POSTERIOR MITRAL LEAFLET PROLAPSE A COMPARISON TO TRADITIONAL TECHNIQUES M.M. Yusuf, H. Luckraz, N. Masani, U.O. Von Oppel University Hospital of Wales, Cardiff, UK Objectives: Posterior mitral valve leaflet (PMVL) prolapse repair using CV5 Gore-Tex neochordae without leaflet resection was used as the primary method of repair. This technique is compared to traditional quadrangular leaflet resection. Methods: Prospective data were collected in 186 consecutive mitral valve repair patients; January 2003 to March 2006. Bileaflet repairs were required in 63 and PMVL only in 54. In the latter group 23 patients underwent repair using neochordae prepared to specific intraoperative measurements using a single suture technique and an annuloplasty ring without any resection (Group 1). The remaining 31 patients underwent more traditional quadrangular resection and an annuloplasty ring (Group 2). We compared immediate and short-term results between these groups. Results: Preoperative mitral regurgitation was severe in 83% (19/23) and 94% (29/31) respectively. Eleven patients in Group 1 (48%) and 4 patients Group 2 (13%) had prolapse of additional segments plus P2. Combined CABG was performed in 35% and 45% of patients respectively. Intraoperative post repair Trans Oesophageal Echo revealed trivial or less residual regurgitation in all patients in Group 1 and 94% of Group 2. At follow-up (FU) 96% of the patients in Group 1 (median FU 12.7 months, IR-5.1 to 19.7) and 94% in Group 2 (median FU 30.1 months, IR – 17.8 to 35.3) were in NYHA class 1 (P=0.74). Transthoracic Echo FU revealed trivial or no regurgitation Group 1–80% and Group 2–75% (P=0.76). There were no operative deaths and 1 late death in each group. Conclusions: Gore-Tex neochordae used as the primary repair technique for PMVL prolapse is reproducible and shows comparable results to traditional quadrangular resection/ reconstruction repair.
1Division of Cardiac Surgery, Second Faculty of Medicine, University of Rome La Sapienza, Rome, Italy; 2Division of Cardiology, Second Faculty of Medicine, University of Rome La Sapienza, Rome, Italy Objectives: To predict the impact of patient-prosthesis mismatch (PPM) assessed by previously published in vivo projected effective orifice area (EOA) on residual pulmonary hypertension (>40 mmHg) after mitral valve replacement (MVR). Methods: Forty consecutive patients (mean age 65±10 years, range 42–82) undergoing MVR had echocardiographic assessment of pulmonary pressure both pre- and postoperatively. A total of 33/40 patients (82.5%) had preoperative pulmonary hypertension (mean 51.1±12.6 mmHg). A multivariate analysis including demographic, operative and echocardiographic data was used to identify independent predictors of residual pulmonary hypertension. PPM was defined as an EOA indexed (EOAi) for body surface area <1.2 cm2/m2. Results: Patients had either biological or mechanical prostheses implanted, sizes ranging from 25 to 33 mm. PPM was found in 14/40 patients (35%). Overall, mean pulmonary pressure improved from 46±18 to 36±7 mmHg (P=0.03). A total of 16/33 patients (48%) with preoperative pulmonary hypertension had no normalisation of pulmonary pressure. Prosthesis characteristics did not differ between patients with and without residual pulmonary hypertension (median size: 29 vs. 27 mm, P=0.75; EOAi 1.43±0.19 vs. 1.41±0.30 cm2/m2, P=0.81). At multivariate analysis the only predictors of residual pulmonary hypertension (r2=41%; P=0.001) were preoperative pulmonary pressure (ß=0.40; P=0.021) and the presence of preoperative atrial fibrillation (ß=0.38; P=0.026). Conclusions: This study shows that PPM assessed by projected in vivo EOAi does not predict early residual pulmonary hypertension after MVR. Normalisation of pulmonary pressure was related with the severity of preoperative pulmonary hypertension supporting the opportunity of an early intervention. A longer-term follow-up is needed to assess the influence of PPM on pulmonary pressure.
1Cardiovascular Surgery Inselspital, Bern, Switzerland; 2Cardiology Inselspital, Bern, Switzerland Objectives: Tissue engineering represents an attractive approach for the treatment of congestive heart failure (CHF). We designed a biodegradable contracting tissue based on a collagen/matrigel and skeletal muscle cells. The aim of the study was to investigate the functional effect of ESMG cardiac implantation after myocardial infarction (MI). Methods: ESMGs were synthesised by mixing rat tail collagen (2 mg/ml), matrigel (2 mg/ml) and skeletal muscle cells (1 million). Two weeks post LAD ligation, animals were randomised in 3 groups: ESMG implantation at the surface of the infracted area using fibrin glue (n=8), fibrin glue deposition only (n=6), sham operation (n=4). Echocardiography was performed 4 weeks later before animals were sacrificed and histology and immunostaining were carried out. Results: Cohesive 3-D patches formed within one week. Cell death was less than 1%. Cell number stayed constant (1.2±0.1 million; 1.1±0.3; 1.2±0.5 at days 2, 5 and, 7 respectively), myoblasts differentiated into randomly oriented myotubes. Four weeks post-implantation, ESMGs were partially degraded and presented dense cellular organisation with neovascularisation as confirmed by smooth muscle actin staining. Mean fractional shortening (FS) was significantly increase in the ESMG implanted group (41%±8 post-implantation vs. 31%±6 pre-implantation, P<0.05). Pre- and post-implantation FS were however not different in the sham-operated and the fibrin-treated animals (respectively: 34%±7 vs. 35%±4 and 33%±5 vs. 35%±3). Conclusions: We demonstrate that ESMG implantation allows a significant functional effect on infarcted hearts. Thus, ESMGs represent promising three-dimensional artificial contractile tissues for cardiac repair.
1Department of Cardiovascular Surgery Heart Centre Brandenburg, Bernau, Germany; 2Institute of Medical Physics and Biophysics Charite, Berlin, Germany Objectives: Various techniques of stentless aortic valve implantation with or without wall components exist. However, haemodynamic performance may differ. We investigated the in-vitro performance of stentless valves with or without aortic wall removal mimicking root versus subcoronary implantation. Methods: Glutaraldehyde-preserved stentless aortic valves (gpSVG) (Köhler Medical), cryo-preserved human homografts (cpHG), cryo-preserved xenografts (cpXG), and fresh xenografts (fXG) of 21, 23, and 25 mm were used. Valves were mounted as full roots or trimmed in a mock circuit and were submitted to physiologic haemodynamic conditions (CO 4.9 l/min). Mean transvalvular gradient (TVG, mmHg) was measured. Distensibility was quantified using end-systolic Backflow Volume (BV, ml). Function was visualised by means of a high-speed camera (1000 frames/s). Results: Glutaraldehyde-preserved stentless valves exhibited higher TVG than cryo-preserved or fresh substitutes. After trimming, cpHG, cpXG, and fXG demonstrated a marked reduction of TVG (cpHG: 7.7–5.4 mmHg; cpXG: 6.9–4.5 mmHg; fXG: 8.0–5.4 mmHg). In contrast, after trimming gpSVG exhibited a significant increase of TVG (8.4–9.3 mmHg). BV remained rather constant in all valves of all types and sizes. Visualisation indicated maintained distension of all valves and types of all sizes after trimming. Conclusions: In fresh and cryo-preserved grafts aortic wall trimming resulted in significantly improved systolic performance while glutaraldehyde-preserved stentless valves demonstrated systolic impairment after wall resection. Subcoronary implantation of fresh or cryo-preserved aortic valves may therefore be preferred instead of the full root or mini-root technique. In contrast, glutaraldehyde-preserved stentless valves are dependent on wall suspension and may therefore be implanted as a root.
Division of Cardiovascular Thoracic and Paediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Objectives: Evaluate distensibility of the aortic root and function of the aortic valve after aortic root replacement using valve sparing procedure. Methods: Between October 1999 and February 2006, valve sparing aortic root replacement was performed in 33 patients with a diagnosis of annuloaortic ectasia (AAE) and aortic valve insufficiency. We performed reimplantation type of valve-sparing procedure with a tube graft (n=10) or a valsalva graft (n=23). Echocardiographic studies were performed 6 months after the operation comparing with valsalva graft (Group V, n=15), tube graft (Group T, n=5), and normal control (Group C, n=5). Percent changes in radius (PCR) were measured as indices of distensibility and rapid valve opening velocity (RVOV /HR (mm/s/min)) and rapid valve closing velocity (RVCV/HR (mm/s/min)) were examined in each group. Results: Root distensibility of sinus PCR in Group V (4.44±2.53) was significantly preserved compared with Group T (1.91±1.19) (P=0.003) and had no significant difference compared with Group C (7.27±1.87). RVOV/HR in Group T was highest among three groups (T: 48.2±6.23, V: 34.8±12.8, C: 33.7±9.6). Conclusions: Sinus distensibility of the valsalva graft was well preserved. Valve-opening characteristics with valsalva graft were identical normal. Aortic valve function is more preserved in valsalva graft.
007 - I ATHEROSCLEROSIS PROGRESSION AFTER PRIMARY CABG: GENE POLYMORPHISMS AS RISK FACTORS FOR ADVERSE EVENTS S. Eifert1, P. Lohse2, A. Rasch1, L. deVries1, G. Nollert1, B. Reichart1 1Department of Cardiac Surgery, Ludwig Maximilians University, Munich, Germany; 2Institute of Clinical Chemistry, Ludwig Maximilians University, Munich, Germany Objectives: Progression of coronary artery disease (CAD) after primary coronary artery bypass grafting (CABG) is frequent and leads to recurrent angina, myocardial infarction, and the need for reinterventions. We hypothesised that classical risk factors of atherosclerosis as well as genetic dispositions may be associated with the progression of CAD. Methods: We investigated 192 patients (18% female, age: 59.2±8.4 years) who had primary CABG at our institution more than 5 years ago. Progression of CAD was defined as the need for reoperations (n=88; 46%), reinterventions (n=58; 30%), or angina at follow-up (n=89; 46%). Gene polymorphisms of the angiotensine metabolism, lipid metabolism (Apolipoprotein E, hepatic lipase, cholesteryl ester transfer protein), coagulation (platelet activator inhibitor-I, prothrombin, activated protein C resistance), and NO donor system (endothelial NO synthase) were determined. Results: Classical risk factors of atherosclerosis (diabetes, smoking history, hypertension, hyperlipidaemia) at the time of primary CABG did not correlate with CAD progression. Single polymorphisms (i.e. angiotensin II type 1 receptor, eNos, ApoE) provided limited information on the reintervention rate. Construction of a gene risk profile facilitated to discriminate among patients with a fast and slower progression of their CAD with respect to all endpoints (P=0.008). Conclusions: Single gene polymorphisms of patients after primary CABG permit a limited prognosis for the progression of CAD. However, gene risk profiles allow risk stratification and may help to understand the pathophysiology of aggressive CAD and to individualise secondary prevention. Further gene polymorphisms have to be investigated to improve this new concept.
1Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany; 2Institute of Circulatory Research, German Sport University, Cologne, Germany Objectives: STAT5 has been indicated to play a protective role in myocardial ischemia-reperfusion (I/R). We investigated the activation of STAT5 in patients subjected to cardioplegic arrest (CA) on cardiopulmonary bypass (CPB) and the impact of the antioxidant N-Acetylcysteine (NAC) on STAT5 regulation. Methods: In 32 CABG patients (66±9 [S.D.] years, 7 women and 25 men) we collected transmural LV biopsies prior to CPB (baseline) and at CPB-end. Patients were randomised in a double-blind fashion to receive either placebo (n=17) or NAC (100 mg/kg into CPB prime followed by infusion at 20 mg/kg/h; n=15). LV specimens were immuno-cytochemically stained against STAT5. Staining was quantitatively determined using densitometry and the number of positive capillaries per viewfield (cpv) was counted. Results: At CPB-end STAT5 was unchanged in both cardiac myocytes and endothelial cells of controls compared to baseline (14.7±3.8 vs. 13.0±3.1 and 129.3±66.9 vs. 135.7±77.8 cpv, P>0.05, respectively). However, STAT5 levels were 10-fold increased in endothelial cells compared to cardiac myocytes. NAC had no effect on STAT5 activation either in cardiac myocytes or in endothelial cells compared to controls. Conclusions: Our data show that STAT5 is activated in endothelial cells but not in cardiac myocytes in patients subjected to CA on CPB. However, STAT5-activity post I/R is unchanged in both cardiac myocytes and endothelial cells. Antioxidant treatment with NAC has no effect on STAT5 regulation.
1Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; 2Hopital Cardiologique Louis Pradel, Lyon, France Objectives: Continuous flow in Fontan circulation is responsible for degradation of pulmonary artery (PA) endothelial function. The objective of this study was to compare, in an animal model, the impact on the PA system of continuous flow in relation to pulsed flow and to show the usefulness of pulsatility. Methods: Creation of three groups of 5 pigs, a sham group, a non-pulsed group and a group with micropulsatility and kept alive for three months. Comparative study was undertaken between the groups and between the right and left lung of each group, of haemodynamic and pulmonary vasorelaxation and vasoconstriction functional changes. A western blot analysis of endothelial nitric oxide synthase (eNOS), was done between the right pulmonary (RP) endothelium artery of each group. Results: The harmful effect of the non-pulsed regimen of RP artery of non-pulsed group by decreasing shear stress was reflected on the RP hypertension (P<0.0001) and on increase in RP resistance (P<0.0015). Response to nitric oxide (NO) was preserved but vasorelaxation to acetylcholine and ionophoric calcium dropped spectacularly (between the non-pulsed group and the sham group: P<0.002). Norepinephrine contraction was increased on the right in comparison with the left side (P<0.001). The relative value for eNOS protein levels was decreased with the non-pulsed group (P<0.05) and normal in the pulsed group. Conclusions: Micropulsatility attenuated the degree of PA hypertension but didn't prevent the degradation of acetylcholine and ionophoric calcium endothelial relaxation. Preservation of the response to NO regardless of the group enables it to be used to avoid increased PA resistance.
1Dokuz Eylul University School of Medicine, Department of Cardiovascular Surgery, Izmir, Turkey 2Dokuz Eylul University School of Medicine, Department of Histology, Izmir, Turkey; 3Dokuz Eylul University School of Medicine, Department of Pharmacology, Izmir, Turkey Objectives: Intimal hyperplasia and proliferation of smooth muscle cells play major role in stenosis occurring after vascular interventions. We investigated the inhibitory effect of adenosine (9-beta-0-ribofuranosyladenine) in the prevention of this pathology in the anastomoses carried out on the carotid artery of rabbit. Methods: Twenty-eight randomised, male, New Zealand type of rabbits were used. Their right carotid arteries were transsected and anastomosed by using 8/0 polypropylene sutures. Group A was the control group. Subcutaneous adenosine was used as 1 mg/kg-day to groups B, C and D for 3, 7 and 21 days, respectively. After 28 day, both anastomosed and contralateral carotid arteries were excised. Digital calculations for luminal diameter, luminal surface area, ratio of the surface areas of intima to media were made. The results are evaluated by using one-way ANOVA, posthoc-LSD and Mann Whitney U tests. Results: Luminal diameter measurements were wider in Group D than both Group A (P<0.0001) and Group B (P<0.001). Luminal areas of Group D was larger than Group A (P<0.0001), Group B (P<0.012) and Group C (P<0.012). When ratios of the surface areas of intima to media were compared, Group D had less intimal hyperplasia than both Group A and B. There was no difference between Groups D and C in this regard. No statistical significance was observed with regards to all parameters between control groups. Conclusions: Adenosine constitutes a further area of investigation by its beneficial effects on preventing intimal hyperplasia and proliferation of smooth muscle cells, in the subject of increasing patency rates after vascular interventions.
Medical University of Vienna, Vienna, Austria Objectives: Re-constitution of blood supply is crucial to rescue myocardial tissue following infarction. Skeletal myoblast transplantation is an attractive alternative in the repair of irreversibly damaged myocardium in ischemic heart failure. However, the majority of transplanted myoblasts undergo apoptosis due to inadequate blood supply. This study addressed this issue. Methods: Three weeks following myocardial infarction, rats developed heart failure and received intramyocardial injections of Ringer's solution, unmodified CSF-1, or autologous myoblasts transfected with CSF-1, VEGF, bFGF, and Ang-1 or with the latter combination supplemented with Ang-2. Real-time RT-PCR was used to measure gene expression, immunocytochemistry to analyze myoblast and macrophage tissue distribution and a Cytoscan(r) OPS imaging device was used to capture in vivo images of the vasculature. Results: The mRNA expression of angiogenic factors increased significantly (P<0.001). Vascular density was enhanced in all rats treated with modified myoblasts compared to other groups (P<0.001). Importantly, rats treated with CSF-1, VEGF, bFGF, Ang-1 and Ang-2 had a functional vascular network with increased vascular diameters compared to other groups (P<0.001). Increased macrophage recruitment and incorporation into vessel walls was observed for both treatment groups, but not in Ringer's solution (P<0.001) or unmodified myoblast groups (P<0.001). Conclusions: Transplantation of genetically modified myoblasts may represent a novel strategy in the treatment of ischemia-induced heart failure by induction of a functional vascular network and enhancement of myoblast survival.
1University of Patras Medical School, Patras, Greece; 2Nottingham City Hospital, Nottingham, United Kingdom; 3St James Hospital, Dublin, Ireland Objectives: Experimental angioscopic and pathological study that set off to investigate whether weaning by mode or by augmentation produces more aortic intimal trauma. Methods: An artificial pulsatile pump was used and an intact porcine aorta was incorporated into the circuit with the inflow at the aortic valve and the outflow at the right common iliac artery. Direct angioscopic images of the interior of the aorta were obtained. Keeping steady haemodynamic conditions, an ‘aortic impact score’ was calculated taking into account angioscopic observational variables and biopsies of the aorta at 30 min, 6 and 12 h following weaning by mode versus weaning by augmentation. Results: Endoscopically the balloon describes a complex movement. There is a ‘whipping’ effect of the balloon shaft on the lateral aortic wall. This appears to be prominent in 1:3 mode. The aortic impact score at 0.5 h during the experiments was: (1) When weaning by mode: (a) 1:1 3.3±0.6, 4.0±1.0 and 4.3±0.6; (b) 1:2 4.7±0.6, 6.7±0.6 and 7.0±0.0; (c) 1:3 8.7±0.6, 11±1.0 and 11.7±0.6. (2) Weaning by augmentation: (a) 75%, 2.3±0.6, 2.7±0.6 and 3.0±0.0; (b) 50%, 1.3±0.6, 1.3±0.6 and 1.7±0.6. An increasing score was observed while weaning by mode. For all pairwise comparisons between the two types of weaning, the differences were statistically significant (ANOVA test). Conclusions: It appears that weaning by mode produces more aortic intimal trauma. 1:3 mode produces marked intimal disruption that worsens with time.
1Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria; 2Department of Cardiothoracic Surgery, Vienna Medical University, Vienna, Austria; 3Institute of Pharmacology and Toxicology, University of Vienna, Vienna, Austria; 4Innovacell Biotechnology, Innsbruck, Austria; 5Institute of Clinical Biochemistry, Innsbruck Medical University, Innsbruck, Austria; 6Department of Haematology, Innsbruck Medical University, Innsbruck, Austria Objectives: Autologous skeletal myoblast transplantation can partially replace infarcted myocardium provided that the injected cells survive in large numbers in the host. Survival of the transplanted cells remains quite low in a setting of chronic myocardial ischemia. We investigated the effect of angiopoietic progenitors delivery in the border zone on the survival of transplanted skeletal myoblasts in chronic ischemic heart failure. Methods: Ischemic heart failure was induced by LAD-ligation in nude rats. A. 106 YFP-labelled homologous skeletal myoblasts (SM) or B. 106 YFP-labelled skeletal myoblasts and 106 DiI-labelled human derived AC-133+ cells (Comb) were injected in the infarct and peri-infarct area, respectively four weeks after infarction. Survival of skeletal myoblasts was assessed by means of confocal microsopy and evaluation of skeletal muscle fast myosin expression by rt-PCR. Apoptotic rates and capillary density were evaluated by means of immunohistochemistry. Results: Injection of angiopoietic progenitor cells in the border zone resulted in improved survival of SM in the infarct area (Comb: 52±13 vs. SM: 31±9/mm2, P=0.007). This effect was confirmed by increased expression of skeletal muscle fast myosin gene in the infarcted myocardium (Comb: 1.11±0.32x106 vs. SM: 0.63±0.21x106, P=0.004). Apoptotic index among viable SM injected in the infarct zone was significantly lower in animals treated by combined cell therapy (Comb: 0.53±0.12 vs. SM: 0.76±0.19, P=0.013). Assessment of capillary density in the infarct scar and the border zone revealed increased neoangiogenesis after combined cell transplantation (Comb: 10.4±2.3 vs. SM: 5.7±1.7, P=0.002). Conclusions: Combined transplantation of angiopoietic progenitor cells in the border zone and SM in the infarct scar improves myoblast survival and attenuates apoptosis by enhancing angiogenesis in chronic ischemic heart failure.
Hiroshima University School of Medicine, First Department of Surgery, Hiroshima, Japan Objectives: Previous studies indicated that high-dose intravenous edaravone (3–10 mg/kg) protects against ischemic spinal cord injury. This study is aimed to examine the efficacy of edaravone injected into the aorta. Methods: Spinal cord ischemia was induced in rabbits by direct aortic cross-clamping (below the renal artery and above the bifurcation) for 15 min at normothermia. In Group A (n=6), 3 mg/kg of edaravone was injected into the clamped segment of aorta. In Group B (n=6) and Group C (n=6), 1 mg/kg of edaravone and saline was injected, respectively, in the same manner. Neurological function was assessed at 8, 24, 48 h and 7 days after reperfusion with Tarlov score. The spinal cord was histologically examined at 7 days with haematoxylin-eosin staining and TUNEL method. Results: Tarlov score was 4 at every measurement point in Group A and Group B, whereas it dropped to 0 or 1 at 7 days in Group C. Mean score was significantly higher at 7 days in the former two groups (4.0, 4.0, and 0.17, respectively, P<0.0001). The number of intact motor neurons was significantly greater in Group A and Group B than in Group C (26.9, 24.5, and 8.6, respectively, P<0.0001) with reduced number of necrotic motor neurons in the former two groups. However TUNEL reaction was negative for apoptotic neurons. There was no significant difference between Group A and Group B. Conclusions: Low dose intraaortic edaravone prevents immediate neurological injury by reducing neuronal necrosis as well as delayed neurological injury at 7 days.
015 - O CLINICAL OUTCOME OF PATIENTS 20 YEARS AFTER FONTAN OPERATION – EFFECT OF FENESTRATION ON LATE MORBIDITY M. Ono, D. Boethig, H. Goerler, M. Lange, M. Westhoff-Bleck, T. Breymann Hannover Medical School, Hannover, Germany Objectives: The Fontan operation has been proposed as definitive palliation for hearts with complex univentricular anatomy, but late morbidity is still a matter of concern. This study evaluates the late outcome in patients with Fontan circulation. Methods: We included 121 consecutive patients that underwent Fontan operation between 1984 and 2004. Modifications of Fontan operation included atriopulmonary anastomosis (APA; n=28), total cavopulmonary connection (TCPC; n=63), and fenestrated TCPC (f-TCPC; n=30). Mean age was 5.8±0.5 years. Post operative mortality, morbidity, haemodynamics, and somatic development were analyzed. Results: Actuarial survival was 87% at 20 years. There were 10 early deaths, 5 late deaths, and 2 take-downs followed by successful conversion and heart transplantation. Among 108 early-survivors, 19 underwent reoperation, including 3 conversions of APA to TCPC. Freedom from reoperation or intervention was 76 and 34% at 20 years. Freedom from tachyarrhythmias or pacemaker implantation was 23 and 77% at 20 years. Heterotaxy and atrioventricular valve anomaly were risk factors for late failure and tachyarrhythmias. Patients with f-TCPC and patients with APA who developed collaterals, showed low incidence of late tachyarrythmias. Postoperative sinus node dysfunction or tachyarrhythmias was associated with significantly lower cardiac index. Somatic development was gradually compensated after Fontan operation. Weight normalised completely 15 years postoperatively. Conclusions: Long-term survival after Fontan procedure is encouraging, but late morbidity remains suboptimal. During follow-up, emerging complications should be managed by surgical and interventional procedures. Fenestration in Fontan circulation provided better cardiac output and lower incidence of tachyarrhythmias, suggesting benefits of fenestration for late outcome.
1National Cardiovascular Centre, Suita, Japan; 2Royal Brompton Hospital, London, UK Objectives: To determine whether preoperative small pulmonary artery could affect the midterm results of Fontan operation. Methods: Between 1992 and 2004, Fontan operation was done in 54 patients having a preoperative pulmonary artery index less than 250 mm2/m2 (Group S, minimum index: 104 mm2/m2). We retrospectively reviewed a consecutive series of these patients, and evaluated midterm Fontan circulation by postoperative catheterisation, hormonal and exercise tolerance test data, and compared it with that of 67 patients who had a larger pulmonary artery index and underwent Fontan operation during the same period (Group L). Results: There was neither early nor late mortality. The latest catheter examinations, at 2.8±2.7 postoperative years, showed a significantly decreased pulmonary artery index in both groups as compared with a preoperative index (Group S: 198±37 to 176±49 mm2/m2, P=0.0082, Group L: 360±94 to 266±89 mm2/m2, P<0.0001). However, the decreases were significantly smaller in Group S (-21±57 vs. –91±110 mm2/m2, P<0.0001). Moreover, there were no significant differences between the two groups regarding other circulatory parameters such as mean pulmonary artery pressure (Group S vs. Group L; 9.8±1.7 vs. 10.3±2.5 mmHg, P=0.2629), cardiac index (3.0±0.7 vs. 3.0±0.6 l/min/m2, P=0.7613), BNP concentration (19.4±15.6 vs. 28.3±37.2 pg/ml, P=0.1231) and peak VO2 (24.8±4.5 vs. 24.0±6.3 ml/kg/min, P=0.7246). Conclusions: Pulmonary artery size decreased after Fontan operation, but the decrease was significantly bigger in those with a larger preoperative pulmonary artery size. In patients having a small pulmonary artery size, the midterm results of the Fontan operation were favourable and not suboptimal compared with those in patients with a larger pulmonary artery size.
Department of Paediatric Cardiac Surgery, Polish American Children's Hospital, Collegium Medicum Jagiellonian University, Cracow, Poland Objectives: The causes of coagulation abnormalities and thromboembolic complications during staged Fontan approach in patients with single ventricle remain unclear. This study was designed to evaluate the coagulation profile in the early postoperative period after hemi-Fontan and Fontan procedures with relationship to liver function and haemodynamic variables. Methods: The prospective study on 43 patients after hemi-Fontan (Group 1) and 37 patients after Fontan procedure (Group 2) was carried out. Coagulation profile (factor VII, factor VIII, ATIII, fibrinogen, prothrombin), liver function (total serum protein, albumin, AST, ALT, bilirubin) and haemodynamic variables were assessed on postoperative day 1 and 5 and compared to preoperative measures. Results: Factor VIII concentration was significantly higher on 1st postoperative day in both groups. On postoperative day 5 the concentration of factor VIII was significantly decreased in Group 1 whereas constant in Group 2. The concentration of factor VII, ATIII, fibrinogen and prothrombin was significantly decreased on 1st and increased on 5th postoperative day after both hemi-Fontan and Fontan procedure. The increase in bilirubin concentration was more distinctive after Fontan operation (P=0.003) with lower AST in this group (P<0.0001). The single ventricle function, pO2 and central venous pressure had significant influence on factor VIII (P=0.034), factor VII (P=0.012), ATIII (P=0.006) and prothrombin (P=0.024) concentration in Group 2 with no significant influence in Group 1. Conclusions: The distinctive causes of coagulation abnormalities during staged Fontan approach are haemodynamic changes and temporary liver dysfunction. Elevated concentration of factor VIII and significant influence of haemodynamics on coagulation profile could contribute to postoperative thromboembolic complications.
Shizuoka Children Hospital, Shizuoka, Japan Objectives: The moderate/severe tricuspid regurgitation (TR) was one of the important risk factors of outcome in Norwood procedure. We have started to evaluate tricuspid valve (TV) by echo cardiogram more precisely and manage TR even if performing stage I Norwood. Methods: We reviewed all patients, (TR: moderate/severe=10, non-TR: mild/trivial=19) who underwent Stage I Norwood with ventricle to pulmonary artery conduit (RV-PA) between January 2001 and March 2007. Results: The median age was 4 days (TR: 3, non-TR: 4) and median weight was 2.9 kg (TR: 3.0, non-TR: 2.8). Three TR patients out of 10 underwent TV plasty in the Stage I Norwood operation. Another two TR patients underwent Norwood with hand made valved RV-PA conduit. In all the TR patients, we controlled pulmonary flow with clipping the RV-PA conduit. In all TR patients, TR was improved significantly after the stage I Norwood (P<0.01). Operative mortality was similar (TR: 0/10, non-TR: 1/19). The actuarial survival rates were 64.8% (TR) vs. 80.2% (non-TR) (5 years) (P=0.38: Logrank). The rate of final completion (Fontan: 12, biventricular repair: 3) was similar (TR 5/10, non-RT 10/19). Conclusions: The appropriate pulmonary flow control and surgical repair in Norwood operation improved the outcome in the operative survival of the patients with HLHS who had moderate/severe TR.
Department of Paediatric Heart Surgery, La Timone Hospital, Marseille, France Objectives: To highlight anatomic lesions and surgical procedures frequently complicated by secondary subaortic stenosis (SSS). Methods: A retrospective study of 4710 patients was performed between 1984 and 2005. The indication for inclusion in the study was the appearance or recurrence after an open or closed-heart operation of a fixed subaortic obstruction, requiring surgery. Fifty-two patients were included. Results: The mean age at initial surgery was 22 months (4 days to 47 years). SSS occurred after five main types of surgery: resection of discrete subaortic stenosis, atrioventricular septal defect repair, coarctation repair, LV-aorta rerouting and Fontan type operation. The mean delay of occurrence was 36 months (2 weeks to 19 years). Frequently associated initial anatomic conditions were left superior vena cava (18%), aortic bicuspidy (33%), coarctation (48%), mitral valve lesion (43%). Pre-operative lesions of the LVOT were present in 92% of cases, but obstructive only in 46%. The most frequent type of SSS was subaortic discrete or extended membrane with or without septal hypertrophy (n=40). Eight patients developed a second SSS 9 years after surgery (mean). One patient developed a third SSS. When compared with patients without SSS, significant risk factors to develop a SSS were low age at surgery (22 vs. 62 months, P<10–4) and preexisting coarctation of the aorta (48 vs. 5%, P<10–4). Conclusions: SSS is a multifactorial lesion depending on both the initial anatomic lesions and the type of surgery. Low age at initial surgery and coarctation of the aorta significantly increase the risk of SSS.
Tokyo Women's Medical University, Tokyo, Japan Objectives: Our strategy for PA with VSD and MAPCA is a staged approach; 1st complete unifocalisation (UF) with ‘unification’ of intrapulmonary arteries and 2nd Rastelli procedure. The purpose of this study is to assess the results of our approach. Methods: From 1982 to 2004, 113 consecutive patients with PA with VSD and MAPCA were treated with staged approach in our institute. We evaluated the risk factor of exclusion from Rastelli procedure or death in 3 years after Rastelli procedure in Logistic regression. Furthermore, we compared early group (patients underwent Rastelli procedure before 1995) and late group (after 1995). Results: Mean follow-up interval was 8.9±6.2 years (0.8 months to 23.3 years), and Kaplan-Meier estimated overall survival rate after 1st UF was 81.0%, 73.6%, and 69.4% in 5, 10, and 15 years, respectively. Survival rate in patients without central PA was significantly lower than in overall patients (60.0% and 51.4% in 5 and 10 years, P<0.05), and the risk factor for exclusion of Rastelli procedure or death in 3 years after Rastelli procedure was absent central PA (P<0.05). In late group, each age at UF (8.5 vs. 3.6 years, P<0.01) and Rastelli procedure (9.0 vs. 5.9 years, P<0.05) was significantly younger, and RV pressure after Rastelli procedure in late group was significantly lower than in early group (74 vs. 55 mmHg, P<0.01). Conclusions: Absent central PA was significant risk factor in this group. RV pressure after Rastelli procedure in late group with staged approach at younger age was improved, and this result may affect long-term outcomes.
Birmingham Children's Hospital, Birmingham, UK Objectives: High concentrations of potassium (K+) and lactate in irradiated red cells (IRC) transfused during cardiopulmonary bypass (CPB) may have detrimental effects on infants and neonates undergoing cardiac surgery. The effects of receiving washed and unwashed IRC from the CPB circuit on serum [K+] and [lactate] were compared. Methods: A control group (n=11) received unwashed IRC and the study group (n=11) received IRC washed in a cell saver (Dideco Electa) using 900 ml of 0.9% saline prior to pump priming. Potassium and lactate concentrations were compared before, during and after CPB. Results: Washing IRC significantly reduced donor blood [K+] from 20 to 0.8±0.1 mmol/l (P<0.001), and [lactate] from 13.7±0.5 to 5.0±0.3 mmol/l (P<0.001). The resulting prime had significantly lower [K+] and [lactate] than the unwashed group (K+ 2.6±0.1 vs. 8.1±0.4 mmol/l, P<0.001; Lactate 2.6±0.2 vs. 4.6±0.3 mmol/l, P<0.001). Peak [K+] in the unwashed group occurred 3 min after going on bypass (4.9±0.3 mmol/l) and during rewarming (4.9±0.4 mmol/l). These were significantly higher than the washed group (3.1±0.1, P<0.001 and 3.0±0.1 mmol/l, P<0.001). The [K+] was greater than 6.0 mmol/l for 4 out of these 11 unwashed patients compared with none of the washed group. Immediately post-bypass the washed group had significantly lower serum [K+] (3.2±0.1 vs. 4.2±0.2 mmol/l, P=0.002). There was no significant difference in [lactate] between groups during and after CPB. Conclusions: The washing of IRC reduces K+ and lactate loads and prevents hyperkalaemia during CPB. The washing of IRC should be considered in neonates and infants undergoing cardiac surgery for complex congenital heart disease.
Royal Hospital for Sick Children, Yorkhill Division, Glasgow, UK Objectives: Peri-operative myocardial injury is a major determinant of post-operative ventricular dysfunction following repair of congenital heart defects. However, changing loading conditions and right ventricular geometry makes functional assessment problematic. We explored the potential of tissue Doppler imaging (TDI) to quantify ventricular function, its relation to myocardial injury and post-operative outcomes. Methods: Twelve children, aged 4–35 months, undergoing corrective repair of congenital heart defects (AVSD, n=7, VSD n=3, ASD n=2) were studied. Troponin-I (cTnI) was measured at 1 and 15 h post-operatively. Simultaneous tissue Doppler and M-mode images were recorded for later off-line analysis. Systolic myocardial velocities, including isovolumetric acceleration and peak annular velocities, were measured in the left and right ventricles and correlated with intra-operative (aortic cross clamp and bypass times) and post-operative variables (inotrope score, ventilation time and ITU stay). Results: Post-operatively there was a significant reduction in RV peak systolic velocities (cm/s) in all patients (pre-op 7.94±3.29; post-op 2.37±0.86; P=0.001). Additionally a strong negative correlation existed between the RV velocities and both cTnI (r=–0.94) and ischaemic time (r=–0.96). By contrast, LV peak systolic velocities demonstrated a variable post-operative pattern and a weaker correlation with cTnI (r=–0.76) and ischaemic time (r=–0.71). Peak LV velocities did however, significantly correlate with post-operative outcomes including ventilation time (r=–0.71) and ITU stay (r=–0.88). Conclusions: This study identified a strong relationship between peri-operative myocardial injury and RV dysfunction as assessed by TDI. Furthermore, LV analysis may be useful in predicting post-operative outcomes.
Oregon Health Sciences University, Portland, USA Objectives: Deep hypothermic circulatory arrest (DHCA) is frequently used for neonates undergoing the Norwood procedure. These infants are severely cyanotic after separation from CPB. Because we have previously demonstrated cerebral autoregulation to be deficient following DHCA, we tested the hypothesis that post-operative cyanosis exacerbates histological brain injury following DHCA. Methods: Neonatal piglets were exposed to 2 h uninterrupted DHCA at 18 °C via aortoatrial CPB, and then supported in our laboratory intensive care, anaesthetised and ventilated with full invasive monitoring. Post-operative oxygenation was controlled to maintain arterial tensions either normoxaemic (NOR, n=5) or hypoxaemic (HYP, n=7) (PaO2 40–50 mmHg) for 24 h. After perfusion-fixing, brains were blindly scored for regional histological injury using light and FluoroJade(tm) fluorescent microscopy. Controls included ‘instrumented without CPB’ (SHAM, n=3)) and non-ischaemic controls (deep hypothermic full-flow CPB, with postCPB hypoxaemia (DHFF, n=3)). Results: Postoperative haemodynamic and acidbase parameters were indifferent. SHAM and DHFF animals were normal and indistinguishable. Normoxaemic animals (NOR) had injury score 7.25±4.5 or 6.25±5.8 by light and fluorescent microscopy. Of hypoxaemic group (HYP), 3 suffered irretrievable brain injury (loss of reflexes, severe cerebral oedema) precluding histological quantification. The remaining 4 had significantly greater ischaemic histological changes (14.5±1.5, P=0.03 and 14.25±2.5, P=0.04). The hippocampal dentate gyrus was consistently most vulnerable. Conclusions: Loss of cerebrovascular autoregulation following DHCA has serious implications for cyanotic staged palliation. Post-CPB cyanosis results in significant amplification of cerebral injury from DHCA. Such infants therefore represent a subset in which DHCA should preferentially be avoided. Techniques for augmenting oxygen delivery (ECMO) may instead protect against this mechanism of injury and warrant investigation.
024 - O LOCAL RECURRENCE MODEL OF MALIGNANT PLEURAL MESOTHELIOMA FOR INVESTIGATION OF INTRAPLEURAL ADJUVANT TREATMENT I. Opitz1, D. Lardinois1, S. Hillinger1, M. Welti1, P. Vogt2, S. Arni1, M. Cardell1, W. Weder1 1Division of Thoracic Surgery, University Hospital, Zurich, Switzerland; 2Division of Clinical Pathology, University Hospital, Zurich, Switzerland Objectives: Development of a standardized local recurrence model for malignant pleural mesothelioma in rats to study local adjuvant therapies. Methods: Recurrence model: A tumour cell suspension of 50 µl 1x106 of rat malignant mesothelioma cells was inoculated subpleurally. Six days later, the tumour nodule was measured and completely resected. Local recurrence at the resection site was assessed after 6 and 10 days. Results: Recurrence model: six days after tumour cell inoculation, all animals developed a tumour nodule at the injection site of a mean diameter of 5.1 mm (±0.8). At 10 days after complete resection, local and distant recurrences in the contralateral chest were found. At 6 days local recurrence only occurred. Local adjuvant treatment with cisplatin-sealant and taurolidine significantly reduced the mean tumour volume of local recurrence from 2200 mm3 in the control to 715 mm3 in the taurolidine to 55 mm3 in the cisplatin-sealant group (P=0.027). Conclusions: We were able to develop for the first time a local recurrence model for MPM in rats. Herewith a significant reduction of tumour growth after local treatment with slow-released cisplatin and taurolidine was demonstrated.
Medical University of Vienna, Vienna, Austria Objectives: Primary graft dysfunction (PGD) is a severe complication in lung transplantation. Therapeutic strategies are limited; and there exist no predictive markers for PGD. Vascular endothelial growth factor (VEGF) is the key regulator of vascular permeability, and its pulmonary tissue levels increase in lung graft oedema. This study sought to investigate whether pre-transplant VEGF serum concentrations could predict PGD. Methods: Pre-transplant VEGF serum concentrations were measured in 120 patients undergoing lung transplantation and in 12 controls by ELISA. The ischaemia time of the grafts and the donors’ PaO2/FiO2 ratios were comparable. PGD was diagnosed and scored from 0 to 3 by characteristic changes in chest radiographs and PaO2/FiO2 ratios according to the International Society for Heart and Lung Transplantation guidelines.
Results: PGD Grades 0–3 occurred in 22, 44, 22, and 12% of patients, respectively. Pre-operative VEGF serum concentrations were significantly higher in patients with PGD Grade 2 (760±508 pg/ml; P=0.008) and 3 (1248±915 pg/ml; P=0.001) vs. those with Grade 0 (367±274 pg/ml) and controls (380±205 pg/ml). VEGF serum concentrations significantly predicted PGD Grades 2 and 3 in receiver operating characteristic curve analysis (P<0.0001, AUC=0.743, CI=1.001–1.003). At a cut-off level of Conclusions: Pre-operative VEGF serum concentrations in patients awaiting lung transplantation could help identifying those at risk for PGD.
1University Federico Ii, Naples, Italy; 2Royal Brompton Hospital, London, UK; 3Monaldi Hospital, Naples, Italy Objectives: This study investigates the prognosis of patients with different extension surgical resection and with different location of N1 nodes. Survival rates were compared between two follow-up patient groups: 1st patient group treated by pneumonectomy with lymph node station involvement or metastatic spread to station 10 and/or 11 and/or direct hilum (fixed node group); 2nd patient group treated by lobectomy with limph node station involvement or metastatic spread 10 and/or 11 and/or hilum (mobile node group). Methods: Of 1146 patients operated, we retrospectively studied 86 follow-up (7.25%) consecutive patients with pN1 disease who underwent a major lung resection for NSCLC, at the Royal Brompton Hospital, from April 1992 to December 2004. Preoperative staging for metastatic disease was negative. No neo-adjuvant or post-operative therapy was given. Detached hilar and mediastinal systematic nodal dissection was performed in all cases. Survival rates were calculated by using the Kaplan-Meier life-table and survival curve comparison by using a long-rank test. Results: The pathology reports revealed 50 squamous-cell, 25 adenocarcinomas, and 11 large cell carcinomas. The overall 5-year and 10-year survival rate in the two groups with N1 disease was 54% (mobile group) and 24% (fixed node) respectively with a median of 66 months. No significant difference was found in the two groups but a better median survival rate in the group treated by lobectomy with mobile node related to the age, sex, pT status, type of lymph node spread. Conclusions: This study confirms the importance of staging lung cancer on TNM, lymphanodectomy and the presence of mobile or fixed node as new prognostic factor.
Uludag University School of Medicine, Bursa, Turkey Objectives: Mediastinoscopy is the most important tool for staging of lung cancer that is performed in almost every lung cancer case with Stage II-IIIb lung cancer. The aim of this study was to compare fine needle aspiration biopsy of mediastinal lymph nodes with tissue biopsy performed during mediastinoscopy. Methods: Sixty-one patients with lung cancer and undergoing staging mediastinoscopy were prospectively enrolled into the study. Tissue biopsies and fine needle aspiration biopsies (FNAB) have been obtained from the same lymph node and sent for a pathologic examination. At least two FNABs were performed from the same lymph node. Tissue biopsies were investigated with frozen section as well as paraffin sections. Tissue biopsies were stained with haematoxylin-eosin (H&E) and fine needle aspiration biopsies with H&E and Giemsa. All specimens were investigated by two different histopathologist. Results: All but three patients were men (3/61, 5%) with a mean age of 56.4 (37–78) years, there was no complication related to both method. Although there were 33 benign reactive hyperplasia and 28 lymph node metastases in tissue biopsies there were 27 benign reactive hyperplasia and 34 lymph node metastases in fine needle aspiration biopsies. Although Classic biopsy revealed four further results when compared to FNAB, FNAB reveals nine further results when compared to classic biopsy. The difference was statistically insignificant (Pearson Chi-Square test P=0.277). Conclusions: Fine needle aspiration is a safe, reliable and effective method when compared to tissue biopsy during mediastinoscopy. It may also further reduce morbidity and give better evaluation of the lymph nodes during mediastinoscopy.
1Marmara University Faculty of Medicine, Department of Thoracic Surgery, Istanbul, Turkey; 2Istanbul University Faculty of Veterinary Medicine, Istanbul, Turkey; 3Marmara University Faculty of Medicine, Department of Pathology, Istanbul, Turkey Objectives: LigaSure (Valleylab, Tyco Healthcare, Boulder, CO) is a novel instrument for vessel sealing which uses heat energy to denature collagen and elastin. We investigated the safety of LigaSure in pulmonary arteries (PA) and veins (PV). Methods: Twelve sheep were endotracheally intubated. Six underwent right lower lobectomy (Group 1) and 6 upper (Group 2). PAs and PVs in both groups were divided using LigaSure. Diameters of vessels were measured. Following vascular division ephedrine was injected to increase PAP in Group 1. In Group 2, animals were followed and euthanized at 7 days. Immediate and 7 day samples were obtained from vessel stumps. Conventional histology was performed. Results: Mean diameter of PAs (n=9) in Group 1 was 8.3 mm (3–11) and of PVs (n=8) was 10.4 mm (4–15). Mean PAP increased from 18 (27/9) to 27 (45/18) mmHg after ephedrine injection. Dehiscence occurred in 2/6 of PAs and 3/6 of PVs larger than 9 mm. Mean diameter of PAs (n=8) divided in Group 2 was 5.7 mm (3–7) and of PVs (n=9) 4.6 mm (4–6). No early or late (7 days) dehiscence was seen in Group 2. No dehiscence was observed in vessels less than 7 mm in diameter. Histology of intraoperative samples showed thermal injury. 7 day samples showed necrosis, thrombus formation without inflammation or granulation tissue. Conclusions: LigaSure achieves perfect sealing in pulmonary vessels less than 7 mm in diameter in sheep intra- and postoperatively following a pressure challenge. It can safely be used in segmental branches of PAs and PVs during open or thoracoscopic surgery.
1Seoul National University Hospital, Seoul, Korea (South); 2Seoul National University Bundang Hospital, Seong-Nam, Korea (South) Objectives: The aim of this study is to identify the impact of extent of lymphadenectomy on the overall survival in oesophageal cancer. Methods: Between January 1995 and December 2003, 239 patients who were operated on due to oesophageal cancer were included in this study. The inclusion criteria were stage I, II, and III oesophageal cancer patients who underwent curative resection without neoadjuvant chemotherapy or chemoradiation. For the analysis of the extent of lymphadenectomy, lymph node stations were classified into 3 regions including upper thoracic, paraesophageal, and abdominal lymph node groups. Lymphadenectomy of 1 region was defined as Group 1, 2 regions as Group 2, and 3 regions as Group 3. Results: The predominant cell type was squamous cell carcinoma (97.1%) and the pathologic stages were stage I in 59 (24.7%), IIa in 70 (29.3%), IIb in 28 (11.7%), and III in 82 (34.3%). There were 69 patients (28.9%) in Group 1, 101 (42.3%) in Group 2, and 60 (25.1%) in Group 3. The 5-year survival of overall patients in Group 1, 2, and 3 was 23.1%, 36.6%, and 55.2% (P=0.02). The 5-year survival of N0 group was 30.1%, 55.3%, and 75.6% in Groups 1, 2, and 3 (P=0.008). The 5-year survival of N1 group was 10.8%, 18.7%, and 36.9% in Groups 1, 2, and 3 (P=0.052). Conclusions: The wider extent of lymphadenectomy in oesophageal cancer showed improved long-term survival than limited lymphadenectomy and especially N0 patients could benefit from the wide extent of lymphadenectomy in this study.
1Seoul National University Hospital, Seoul, Korea (South); 2Seoul National University Bundang Hospital, Seong-Nam, Korea (South) Objectives: The aim of this study is to identify the role of surgical resection in malignant mediastinal neurogenic tumour in children. Methods: Between 1986 and 2004, 38 consecutive children who underwent surgical resection of malignant mediastinal neurogenic tumour were included in this study. The cell types of tumours were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for the purpose of curative resection in localized tumours and salvage resection of residual mediastinal mass after chemotherapy in stage IV tumours. Of 16 patients (42.1%) who underwent salvage resection, there were 14 neuroblastomas and 2 ganglioneuroblastomas. Results: Mean age of patients was 3.4±3.0 years (1 month–13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in 8 patients (21.1%), which was invasion of chest wall in 4, atrium and vena cava in 2, lung in 1, and chest wall and lung in 1. Complete gross resection was possible in 31 patients (81.6%) and there was no surgical mortality. Surgical morbidity occurred in 9 patients (23.7%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 89.3% for localized tumour and 39.6% for stage IV tumour (P=0.001). The significant risk factors for long-term survival were adjacent structure invasion (P=0.004) and stage IV tumour (P=0.032) in multivariate Cox regression analysis. Conclusions: Surgical resection of localized malignant mediastinal neurogenic tumour in children showed good long-term survival and salvage operation after chemotherapy also showed acceptable long-term survival.
Ondokuz Mayis University School of Medicine, Samsun, Turkey Objectives: In clinical practice of the thoracic surgery, after lung resection, the thoracic cavity may be filled partially or completely by the remaining pulmonary tissue. However, we have not been able to find a study evaluating quantitatively this volumetric change of thoracic content using high resolution computed tomography (HRCT). We aimed to evaluate quantitatively the volume changes of lungs using HRCT in the preoperative and postoperative period. Methods: In this study, we used HRCT on 17 patients with lung cancer taken preoperatively and one month later the resection operation. All the patients were male and their ages, weights and heights were 58.7 (40–76) years, 72.41 (46–80) kg, 1.73 (1.56–1.90) m, respectively. The volume and volume fraction of the lung were estimated by means of applying the point counting grids over the preoperative and postoperative HRCT. Total volumes of the pulmonary tissues were 6.58 and 4.58 litres in preoperative and postoperative periods, respectively. Results: While 30.41% pulmonary tissue was resected, the pulmonary tissue was diminished volumetrically in 22.35%. Volumetric analyses showed that the remaining tissues increased their volume in 8.06% to fill the thoracic cavity. Conclusions: Our results showed that the volume and volume fraction of the total pulmonary tissues could be evaluated on HRCT using the proposed method. The method could provide information to predict the postoperative progress before the resection.
033 - O FONTAN COMPLETION WITHOUT SURGERY A. Sallehuddin, F. Fadley, M. Barakati, M. Fayyadh, A. Mesned, Z. Halees King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Objectives: To describe the outcome of a combined surgical-interventional technique for the creation of total cavo-pulmonary connection. Methods: During bidirectional Glenn, an intra-atrial lateral tunnel was created and fenestrated with a 10—14-mm hole. The cardiac end of SVC was patched to establish bidirectional physiology. During interventional completion, this patch was perforated using radio-frequency energy and stented. The fenestration was closed with a device. Paired t-test was used to compare data before and after Fontan. Results: From June 2003 to February 2006, 16 patients (9 boys and 7 girls, mean age 12 months) underwent the surgical procedure described. Mean bypass time was 137 min and mean ischemic time 77 min. There were no deaths. One patient with bilateral SVC required takedown due to recurrent effusions. 10 months later, 9 patients underwent completion (mean age 20 months, mean weight 10.6 kg). All except one fenestration was closed with a device. Stents were dilated to 14.4 mm average. Mean fluoroscopy time was 41 min. Oxygen saturation increased 85–94% (P=0.001). Pulmonary artery pressures remained normal (16 before and 19 mmHg after, P=0.12). None required mechanical ventilation. None developed effusions. All were discharged from hospital within 6 days. Twenty-two months after Fontan, all were well. Echocardiography revealed no gradients across the stents. Two patients had minor leaks across the fenestration. One underwent further stent dilatation 1 year later. Conclusions: Fontan without surgery is suitable in single ventricles with lower mortality and morbidity, avoids multiple surgical interventions while maintaining the staged approach and allows for successive dilatations.
Department of Cardiothoracic Surgery and Anaesthesiology, Örebro, Sweden Objectives: Conventional harvesting of the saphenous vein in coronary artery bypass surgery produces vessel damage that contributes to graft failure. A novel ‘no touch’ technique provides a higher short and long term patency rate. Methods: This randomised longitudinal trial compares the graft patency of two patient groups undergoing coronary artery bypass surgery. Conventional (C): 52 patients had their veins stripped, distended and stored in saline solution. No-touch (NT): 52 patients had veins removed with surrounding tissue, not distended and stored in heparinised blood. Angiographic assessment was performed at mean time 18 months after the operation in 46 patients in Group C and 45 patients in Group NT and repeated at mean time 8.5 years in 37 patients from both groups. Results: The distribution of the grafts to the recipient coronary arteries regarding their size and quality was similar in both groups. The angiographic assessment at 18 months postoperatively showed that 89% Group C vs. 95% Group NT grafts were patent. Repeated angiography at 8.5 years showed a patency rate for the C group of 76% and 90% for the NT group, P=0.01. The multivariate analysis showed that the most important surgical factors for graft patency were the technique of harvesting (P=0.007) for the NT vs. the C technique and the vein quality before implantation (P=0.007) for veins that were of good quality. By comparison the patency of the mammary artery grafts was 90%. Conclusions: Harvesting the saphenous vein with surrounding tissue provides high short and long term patency rate comparable to the left internal mammary artery.
1Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland; 2Department of Pathology, Jagiellonian University, Krakow, Poland; 3Department of Radiology, Jagiellonian University, Krakow, Poland Objectives: To compare the diagnostic yield of standard mediastinoscopy and transcervical extended mediastinal lymphadenectomy (TEMLA) in detecting metastatic mediastinal lymph nodes in NSCLC patients. Methods: Prospective, randomised, single-blind clinical study. Results: 41 NSCLC patients were randomised: 21 to the TEMLA group and 20 to the mediastinoscopy group. Both groups were comparable regarding patient's age, gender, cTNM, histology and location of the tumour. The TEMLA revealed mediastinal metastases in 7 patients, and mediastinoscopy in 3. In patients with negative nodes, thoracotomy with appropriate pulmonary resection and mediastinal dissection was performed: in 13/14 patients from TEMLA group and in 15/17 patients from mediastinoscopy group. Unsuspected metastatic N2 nodes were discovered in operative specimen after thoracotomy in 5/15 patients from mediastinoscopy group vs. 0/13 patients in TEMLA group (P=0.019); this significant difference was the reason of terminating the randomisation before reaching the initially planned number of 100 patients. The sensitivity of mediastinoscopy was 37.5% and its negative predictive value was 66.7%, comparing with 100% and 100% in the TEMLA group. Conclusions: The sensitivity and the NPV of the TEMLA in detecting mediastinal metastases in NSCLC patients are significantly greater than that of cervical mediastinoscopy.
Marie Lannelongue Hospital, Le Plessis-Robinson, France Objectives: To identify anatomical and surgical factors influencing the early and late outcome in patients with complex coronary artery anatomy undergoing arterial switch operation (ASO). Methods: Since 1991, 1195 consecutive patients underwent ASO. Forty-five (3.8%, 70% CL: 3.2-4.4%) presented with inter-arterial (type C, Yacoub) coronary artery course. Both coronary arteries were arising from sinus #2 in 33 and from sinus #1 in one. In the remaining 11, at least one of coronary ostia was located above the posterior aortic valve commissure. Intramural course was observed in 27, 5 associated with an ostial stenosis. Sixteen (35%) had associated VSD. The operative technique consisted in detachment of the posterior commissure and excision of the coronary ostia as a single disc in all. The latter was relocated with use of a PTFE hood in 3. In 42, following division into two cuffs, a uniform transfer technique was employed. Unroofing of the intramural segment was performed in 12. Results: There were 7 hospital deaths (15.5%, 70% CL: 9–23%), 6 due to coronary malperfusion. All were associated with initial intramural course. Follow-up was complete in all survivors. Three patients (6.6%, 70% CL: 2–13%) died second month after discharge because of acute myocardial ischaemia. Four patients required left coronary artery bypass procedure 4, 36, 60 days and 9 years after repair with good recovery. Conclusions: ASO in patients with inter-arterial/intramural coronary course remains associated with frequent coronary ischemic complications. Coronary artery bypass procedure for postoperative myocardial ischaemia appears to be life saving.
Erasmus University Medical Centre, Rotterdam, Netherlands Objectives: Whether allografts are the biological valve of choice for AVR in nonelderly patients remains a topic of debate. In this light we analysed our ongoing prospective allograft AVR cohort and compared allograft durability with other biological aortic valve substitutes. Methods: Between April 1987 and October 2005, 336 patients underwent 346 allograft AVRs (95 subcoronary, 251 root replacement). Patient and perioperative characteristics, cumulative survival, freedom from reoperation and valve-related events were analysed. Using microsimulation, for adult patients age-matched actual freedom from allograft reoperation was compared to porcine and pericardial bioprostheses. Results: Mean age was 45 years (range 1 month to 83 years), 72% were males. Etiology was mainly endocarditis 32% (active 22%), congenital 31%, degenerative 9%, and aneurysm/dissection 12%. 27% underwent prior cardiac surgery. Hospital mortality was 5.5% (n=19). During follow-up (mean 7.4 years, max 18.5 years, 98% complete) 54 patients died, there were 57 valve-related reoperations (3 early technical, 12 non-structural, 38 structural valve deterioration (SVD), 4 endocarditis), 5 CVAs, 1 fatal bleeding, 8 endocarditis. Twelve-year cumulative survival was 71% (SE 3), freedom from reoperation for SVD 77% (SE 4); younger patient age was associated with increased SVD rates. Actual risk of allograft reoperation was comparable to porcine and pericardial bioprostheses in a simulated population. Conclusions: The use of allografts for AVR is associated with low occurrence rates of most valve-related events but over time the risk of SVD inc |
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Monday 11 September 2006...
Monday 11 September 2006...
650 pg/ml serum VEGF had 83% sensitivity and 77% specificity to identify PGD Grade 3 vs. Grade 0 (P=0.005).